1. Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Kenny DeSart, M.D.
Postoperative Fever
Tad Kim, M.D.
Connie Lee, M.D.
Michael Hong, M.D.
Kenny DeSart, M.D.

2. Pathophysiology Fever >38ºC is common after surgery
Most early postoperative fever is caused by the inflammatory stimulus of surgery and resolves spontaneously
Fever = response to cytokine release
Fever-associated cytokines are released by tissue trauma and do not necessarily signal infection
Cytokines produced by monocyte, macrophages, endothelial cells
Fever-associated cytokines = IL-1, IL-6, TNF-alpha, IFN-gamma

3. DDX: The 5 W’s Wind (POD#1) Atelectasis, pneumonia
Water (POD#3) UTI, anastomotic leak
Wound (POD#5) Wound infection, abscess
Walking (POD#7) DVT / PE
Wonder-drug or What did we do?

4. DDX: Immediate Fever
Immediate fever: onset in OR or in the immediate postoperative period
Go look at the wound
DDX:
Medication reactions: antibiotics, blood products, malignant hyperthermia. Often p/w hypotension.
Necrotizing infection: Clostridium, Group A β-hemo strep. Treatment: ABC, resuscitate, ABX: pip/tazo and clindamycin, surgical debridement

5. DDX: Fever DDX: Necrotizing infection (within 48hrs)
Anastomotic leak (classically POD# 3 to 5)
Pulmonary embolism
Pneumonia/Aspiration
UTI
Surgical site infection (SSI)
Deep abscess
ETOH withdrawal
Clostridium difficile colitis
CVL infection
Other: acute gout, pancreatitis

6. Evaluation ABCs Resuscitate
HPI: anesthesia record, operative note, nursing report, flowchart
PE:
Complete exam
Look at wounds - take off dressings
Look at drain output
Check PIV sites, CVL, Foley, tubes

7. Labs/Studies Labs to order if concerned for infection:
CBC w diff, sputum Cx, UCx, Blood Cx x2
Lumbar puncture (if AMS, neck pain, fever-rarely ordered)
C. diff toxin assay from stool
Imaging:
CXR (for pneumonia)
Lower extremity venous duplex (for DVT)
CT scan (for abscess, leak, pancreatitis, PE)
Usually wait until POD5
RUQ ultrasound (for cholecystitis)

8. Management Remove/replace sources of infection
Foley catheter, central lines, or peripheral IV’s
Open, debride, and drain infected wounds
Antibiotics typically not prescribed for superficial wound infection
If suspect pneumonia, bacteremia, UTI, sepsis – start broad spectrum antibiotics
Anticoagulation for DVT/PE
CT guided drainage of abscess

9. Case 1
58y M 5hrs after B/L total knee arthroplasty. Temp 38.7 C. Pain adequately controlled w/meds. No antibiotics.
PE: HR 90, BP 130/70, O2 sat: 99%
Mild serosanguinous drainage from knees
No Foley or CVL
WBC 7
What is your plan?

10. Case 1 What is your plan? A. Urine culture
B. Blood, urine cultures & CXR
C. Blood, urine cultures & vancomycin
D. Observation only

11. Case 2
65y F w/ obesity, DM now 5hrs s/p open cholecystectomy for gangrenous cholecystitis c/o abdominal pain. Temp 40C, tachycardia.
VW: HR 140, BP 88/50, O2 Sat 94%
PE: AMS, wound is blistered, +crepitus, w/ dirty dishwater drainage
What is your diagnosis?
What is your plan?

12. This patient is in septic shock
Case 2
What is your diagnosis?
Cellulitis
Diffuse peritonitis
Necrotizing fasciitis
Uncomplicated post operative fever
What is your plan?
Observe
ABC, resuscitate, IV antibiotics
ABC, resuscitate, IV antibiotics, immediate surgical debridement
This patient is in septic shock

13. Case 3
61y F w rheumatoid arthritis on methotrexate undergoes left total hip replacement. Foley catheter present postoperatively. POD#1 temp 38.1C, Foley is removed. POD#4 temp 38.5 C.
She has been ambulating and using incentive spirometry
PE: O2 Sats and vitals are normal, wound is clean
What is the diagnosis?
What is the plan?

14. Case 3 What is the most likely diagnosis? A. Deep venous thrombosis
B. Urinary tract infection
C. Superficial wound infection
D. Prosthesis infection
UTI evaluation: history, U/A, urine culture
Evaluate for other possibilities

15. Take Home Points The 5 W’s Think the worst and rule it out!
Must correlate clinically
USE COMMON SENSE!!!
Necrotizing fasciitis must be identified and treated aggressively